Ethical and Practice
Considerations in Telehealth for
Couples Interventions
Presented by Nate Rhoad, B.S., Olivia McFarland, B.S., Jennifer
Ripley, Ph.D
Overview
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What is Telehealth?
Telemental Health
General Ethical Considerations
E-Hope Couples Consultation
Ethical Issues Specific to Couples Work
Case Studies
A Changing World
http://www.apa.org/divisions/div46/technology-1.jpg
A Changing World
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Advancement in technology
o Increased pace and decreased cost
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Increasing popularity of social media
Familiarity with technology
Consumer Demand
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Needs of younger generation
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Individual’s in rural areas
Maheu et al., 2012
What is Telehealth?
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The use of electronic info and telecommunication
to support and improve clinical health services,
health administration, patient info, public health,
and professional education and supervision (Baker
& Bufka, 2011)
Technologies include videoconferencing, the
internet, streaming media, store and forward
technologies, and terrestrial and wireless
communications (Baker & Bufka, 2011)
What is Telehealth?
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Did you know?…
o Concept of Telehealth not a novel one
o 1879- Article in the Lancet discussed using
phone to reduce office visits (Nesbitt, 2012)
o 1925- Cover of Science and Invention shows
doctor diagnosing patient by radio (Nesbitt,
2012)
o Video teleconferencing used in Dept. of
Veterans Affair for almost 20 years (Novotney,
2011)
Telemental Health
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Terms include “telemental health”, “e-mental health”, and
“telepsychology”
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Email use with clients more than tripled from 2000 to 2008 among
psychologists
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Teleconferencing increased from 2 to 10 percent in same time period
Ability to potentially provide services to millions of people who could
ordinarily not access psychological services due to immobility, illness, or
geographic location
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Nearly 80 million live in a “mental health shortage area”
Novotney, 2011
Telemental Health
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Has been used to treat various psychological problems (Novotney, 2011)
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PTSD, substance use, anger management
Is it effective?
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2008 meta-analysis of 92 studies did not find sig. difference between
face to face and telemental health approaches
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Has been found to effectively treat PTSD symptoms and anger
problems
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Study of 98,000 mental health patients (Godleski, Darkins & Peters,
2012)
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Hospitalization utilization decreased by average of 25% between
2006 and 2010 when teleconferencing was used
The Human Element
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Is therapeutic alliance diminished when videoconferencing is
used?
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Study conducted examining the difference in alliance between
face to face and videoconference therapy (Germain et al.,
2010)
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46 participants diagnosed with PTSD (17 over video, 29 in person)
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Assessments analyzing alliance administered five times
throughout treatment
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Alliance was found to develop similarly in both conditions
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Those who had concerns about technology had no trouble
building alliance with their therapist
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Therapists can impact client’s view by maintaining positive
attitude about videoconferencing
Effectiveness with Couples
• Study investigated the outcomes of 11 couples who
participated in solution focused marital therapy (Jedlicka &
Jennings, 2001)
• Conducted via email
• Outcomes were similar to face-to-face therapy, with strength
of outcome associated with couples investment in problem
solving
General Ethical Considerations
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Currently, APA does not have official policy
regarding use of telemental health
However… APA and Association of State and
Provincial Psychology Boards (ASPPB) Model
Acts of Licensure of Psychologists note that
psychological care may be provided
electronically or over the phone
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Jurisdictional Restrictions
Baker & Bufka (2012)
Jurisdictional Restrictions
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Telepsychology 50- State Review
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States differ in statutes and regulations in place for
telepsychology (many states do not have them)
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All states have regulations for licensed psychologists who practice
telepsychology in states they aren’t licensed in
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All states implement a penalty for those who practice
telepsychology without license (just as in the general practice of
psychology)
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http://www.apapracticecentral.org/advocacy/state/telehealthslides.pdf
General Ethical Considerations
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Informed Consent
Safety and Security Online
o Email
o Videoconferencing- Use of Skype?
Reimbursement Concerns
Training
Baker & Bufka (2012)
Ethics Statements Across the “Boards”
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American Association of Marriage and Family Therapists
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“When using electronic methods for communication, billing, recordkeeping, or other
elements of client care, marriage and family therapists ensure that their electronic data storage
and communications are privacy protected consistent with all applicable law.” AAMFT Code of
Ethics, 2012, 2.7 Protection of Electronic Information
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American Counseling Association
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“Counselors take precautions to ensure the confidentiality of all information transmitted
through the use of any medium.” ACA Code of Ethics, 2014, B.3.e
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National Association of Social Workers
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“Social workers should take precautions to ensure and maintain the confidentiality of
information transmitted to other parties through the use of computers, electronic mail, facsimile
machines, telephones and telephone answering machines, and other electronic or computer
technology. Disclosure of identifying information should be avoided whenever possible.” NASW
Code of Ethics, 1996, Revised 2008, 1.07.m
http://www.zurinstitute.com/ethicsoftelehealth.html#aamft
Hope Model
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Short term strategic
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Religion-accommodative
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New model: attachment, positive psychology/virtues
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Reviewed one of 4 empirically supported treatments for marriage
enrichment (Jakubowski et al., 2005)
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20 years of research at VCU (Worthington et al) and 14 years at
Regent U.
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Two books on it Worthington (2005) Ripley & Worthington (2014)
E-Hope Consultation
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A model based on couple education and enrichment
Each couple is matched with a consultant who directs and guides
them through the process
The couple can choose their own modules and materials to work
through
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Modules consist of worksheets, videos, blogs & Vsee conversation
The consultant also suggests relevant materials
The consultant meets with the couple two times a month over a period
of two months
Why Consultation?
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Couples should not have serious psychopathology, serious
violence, substance abuse, separation, or significant
relational problems
Emphasis on enrichment rather than counseling
If serious distress or issues become relevant, couples will be
referred for counseling
Consultant supports couple in meeting their relationship goals
and growth
o couples counseling is to assist with healing and repair
from dysfunctional relationship patterns
Ethical Issues Specific to Couples Work
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Screening couples for
suitability
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Connectivity Issues
Referral and Safety Issues
Confidentiality
Informed Consent
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Education
Consultation environment
Couples may not have as
secure of an environment
as the consultant (Bischoff,
2004)
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Mental Status (Bischoff, 2004)
May be difficult to obtain
for two individuals
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Case Studies
• African American Couple
• Mid 40s
• Seeking online couples consultation due to busy
schedule
• Main concerns are in the area of communication
References
Baker, D. C. & Bufka, L. F. (2011). Preparing for the Telehealth World: Navigating Legal,
Regulatory, Reimbursement, and Ethical Issues in an Electronic Age. Professional Psychology:
Research and Practice, 42(6), 405-411.
Bischoff, R.J. (2004). Considerations in the Use of Telecommunications as a Primmary TreatmentMedium: The
Application of Behavioral Telehealth to Marriage and Family Therapy. The American Journal of
Family Therapy, 32(3), 173-187.
Campos, B. (2009). Telepsychology & Telehealth: Counselling Conducted in a Technology
Environment. Counselling, Psychotherapy, and Health, 5(1), The Use of Technology in Mental
Health Special Issue, 26-59.
Germain, V., Marchand, A., Bouchard, S., Guay, S., & Drouin, M. (2010). Assessment of the Therapeutic
Alliance in Face-to-Face or Videoconference Treatment for Posttraumatic Stress Disorder.
Cyberpsychology, Behavior, and Social Networking, 13(1), 29-35.
Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 U.S.
Department of Veterans Affairs patients enrolled in telemental health
services, 2006–2010. Psychiatric Services, 63, 383–385. doi:10.1176/
appi.ps.201100206
References
Jedlicka, D., & Jennings, G. (2001). Marital therapy on the Internet. Journal of
Technology in Counseling, 2, 1–15.
Keeran, D. M. (2009). Effective counseling skills: the practical wording of therapeutic
statements and processes. Vancouver, British Columbia, Canada: Counselor
Publishing.
Maheu, M. M., Pulier, M. L., McMenamin, J. P., & Posen, L. (2012). Future of Telepsychology,
Telehealth, and Various Technologies in Psychological Research and Practice.
Professional Psychology: Research and Practice, 43(6), 613-621.
Nesbitt, T. S. (2012). The Evolution of Telehealth: Where Have We Been and Where are We
Going? In The Role of Telehealth in an Evolving Health Care Environment-Workshop
Summary. Retrieved from http://www.iom.edu/Reports/2012/The-Role-ofTelehealth-in-an-Evolving-Health-Care-Environment.aspx
Novotney, A. (2011). A New Emphasis on Telehealth: How can psychologists stay ahead
of the curve-and keep patients safe? Monitor on Psychology, 42(6), 40.